M D I A

Transcription

M D I A

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THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
Vol. 29, No. 1, pp. 19–53, 2003
Effectiveness of Substance Abuse Treatment
Programming for Women: A Review†
Olivia Silber Ashley,1,* Mary Ellen Marsden,1
and Thomas M. Brady2
1
RTI, Research Triangle Park, North Carolina, USA
Office of Applied Studies, Substance Abuse and Mental Health Services
Administration, Rockville, Maryland, USA
2
ABSTRACT
Recent research has shown that women and men differ in substance abuse
etiology, disease progression, and access to treatment for substance
abuse. Substance abuse treatment specifically designed for women has
been proposed as one way to meet women’s distinctive needs and reduce
†
This article was developed for the Substance Abuse and Mental Health Services
Administration (SAMHSA), Office of Applied Studies (OAS), by RTI, Contract No.
283-99-9018. The study was managed under National Analytic Center (NAC) for the
National Household Survey on Drug Abuse (NHSDA) and Other Data. Charlene Lewis
is the NAC Project Officer. This work does not represent policy or the position of the
Office of Applied Studies, the Substance Abuse and Mental Health Services
Administration, or the U.S. Department Health and Human Services, and no official
endorsement by any of these organizations is intended or should be inferred.
*Correspondence: Olivia Silber Ashley, RTI, P.O. Box 12194, Research Triangle Park,
NC 27709-2194, USA; Fax: (919) 485-5555. E-mail: osilber@rti.org.
19
DOI: 10.1081/ADA-120018838
Copyright q 2003 by Marcel Dekker, Inc.
0095-2990 (Print); 1097-9891 (Online)
www.dekker.com
20
Ashley, Marsden, and Brady
barriers to their receiving and remaining in treatment. However, relatively
few substance abuse treatment programs offer specialized services for
women, and effectiveness has not been fully evaluated. This article
reviews the literature on the extent and effectiveness of substance abuse
treatment programming for women and provides an overview of what is
known about the components of successful treatment programs for
women. Thirty-eight studies of the effect on treatment outcomes of
substance abuse treatment programming for women were reviewed.
Seven were randomized, controlled trials, and 31 were nonrandomized
studies. In our review, six components of substance abuse treatment
programming for women were examined: child care, prenatal care,
women-only programs, supplemental services and workshops that
address women-focused topics, mental health programming, and
comprehensive programming. The studies found positive associations
between these six components and treatment completion, length of stay,
decreased use of substances, reduced mental health symptoms, improved
birth outcomes, employment, self-reported health status, and HIV risk
reduction. These findings suggest that to improve the future health and
well-being of women and their children, there is a continued need for
well-designed studies of substance abuse treatment programming for
women.
INTRODUCTION
Substance abuse in women has a distinctive etiology, disease progression,
and concomitant treatment needs. In the early 1970s, the National Institute on
Drug Abuse (NIDA) developed a small program to deal with the problem of
substance abuse treatment for women. The growth of such programs
languished until the crack cocaine epidemic of the 1980s focused attention on
crack-addicted women, and particularly, their children (1,2). One response in
the late 1980s to the increase in cocaine use was increased funding under the
substance abuse block grant for treatment programs serving women. In
October 1988, Congress passed the Anti-Drug Abuse Act, which mandated a
10% set-aside for grants to public, private, and not-for-profit entities to fund
demonstration programs for substance-abusing pregnant and postpartum
women and their infants (3). This funding further ignited interest in women’s
treatment services (4,5). Now a growing body of research shows that
substance abuse among women and the issues surrounding their abuse differ
from that among men, requiring a specialized set of therapeutic interventions.
A recent Institute of Medicine report has highlighted sex as an important
Substance Abuse Treatment Programming for Women
21
variable that should be considered when designing and analyzing biomedical
and health studies (6).
Unfortunately, these findings are just beginning to influence the way
substance abuse treatment is provided for women, and few studies have
examined the effectiveness of substance abuse treatment services for women.
This article reviews the published literature on the extent and effectiveness of
substance abuse treatment programming for women.
Women substance abusers differ from men in the antecedents of
substance abuse, frequently initiating substance use as a result of traumatic life
events such as physical or sexual violence, sudden physical illness, an
accident, or disruption in family life (7 –9). Women substance abusers are
often drawn into substance use by partners (10,11) or are raised in an
environment of heavy drinking or drug abuse (12,13).
Women demonstrate unique psychosocial characteristics associated with
substance abuse. Women substance abusers are more likely than men to have
poor self-concepts (low self-esteem, guilt, self-blame) and high rates of
mental health problems, such as depression, anxiety, bipolar affective
disorder, suicidal ideation, psychosexual disorders, eating disorders, and
posttraumatic stress disorder (14 –25). Furthermore, social stigma, labeling,
and guilt serve as significant barriers to women’s receiving treatment (7 – 9),
and programs that treat men and women clients together are less able to attract
and retain especially vulnerable women, such as lesbian women, women with
a history of physical or sexual violence, and those who have worked as
prostitutes (7,26 –28).
Entering, engaging, and remaining in substance abuse treatment may
require not only the availability of specialized treatment services but also an
array of resources to help with specific issues, such as child care and physical
and mental health (30). Using data from a large multisite prospective clinical
epidemiological study, Wechsberg and colleagues (29) found that women
entering substance abuse treatment were younger and had lower education and
employment levels, health and mental health problems, greater exposure
to physical and sexual abuse, and greater concerns about issues related to
children compared with men. Responsibility for children, lack of access to
child care services, and society’s punitive attitude toward substance abuse by
women as childbearers are barriers frequently cited by women who need help
(7,31 – 34). In the 1980s, legislated offenses penalized chemically dependent
mothers who used drugs during their pregnancies (35). Transportation to
treatment sites has also been identified as a barrier for women (32,36).
Furthermore, the interplay of gender-specific drug use patterns and sex-related
risk behaviors creates an environment in which women are more vulnerable
than men to infection with human immunodeficiency syndrome (HIV)
22
(37,38). For instance, women are more likely than men to inject drugs, use
drugs with many partners, share paraphernalia after an injection partner,
exchange sex for money or drugs, and have difficulty negotiating condom use
with their sex partners (37).
A few studies have identified additional special needs of women. For
example, women substance abusers are more likely than their male
counterparts to report greater dysfunction in the family of origin (39), lacking
adequate role models for parenting (40,41). Poor interactions with children
can be a significant source of stress that interferes with treatment efforts
(41,42). Women substance users are also more likely than male substance
users to enter dependent relationships dominated by their partner (43),
hindering their ability to perform basic life skills, such as managing money
and planning for the future. Furthermore, women in treatment may need
female role models for recovery. In fact, research in the 1980s found that
structural factors of treatment facilities such as staff composition influenced
use rates by women and impacted their entry and continuation in treatment
(44,45).
For the purposes of this article, we use the term “substance abuse
treatment programming for women” to refer to the delivery of services that
(1) reduce women’s barriers to entering substance abuse treatment and/or
(2) address the substance abuse treatment needs unique to women. There is no
widely accepted definition of substance abuse treatment programming for
women, but such treatment includes:
1.
2.
3.
4.
Social and medical ancillary services intended to increase women’s
access to substance abuse treatment, such as child care or
transportation.
Services intended to address special needs of women, such as
prenatal care, psychosocial education, women-focused HIV
prevention, or mental health programs.
Programs and services for women only, creating a unique treatment
environment that is more focused on women’s issues and a more
comfortable setting in which women may discuss sensitive and
painful issues.
Modalities tailored to women’s special needs: a nurturing and
supportive group therapy environment, emphasis on self-worth, or
treatment that addresses the multiple roles of women (mother,
partner, friend).
This latter type of substance abuse treatment programming for women
focuses on how services are delivered rather than on the type or quantity of
23
services. Treatment programs may incorporate a combination of two or more
of the above factors.
Because substance abuse treatment programming for women is not a
single intervention but consists of multiple interventions, determining the
availability of such programming is difficult. However, the availability of
some specialized services for women has been examined in several
studies. The 1998 Uniform Facility Data Set (UFDS), a survey of
facilities providing substance abuse treatment, found that 19% of facilities
offered special programs for pregnant or postpartum women, whereas
28% offered special programs for other groups of women in treatment
(46). These special programs for women were most often offered at local
government-owned facilities, community mental health centers, and mixed
outpatient and residential facilities. Almost 9% of all facilities offered
child care, 7% offered prenatal care, and 5% offered perinatal care. More
than one third (36%) offered transportation to treatment.
A 1994 survey of 161 drug treatment programs for adults in Los
Angeles County found that 19% were women-only programs (47).
Compared with mixed-gender programs, women-only programs were more
likely to report priority admission for pregnant women, no fees, and longer
planned treatment duration. They were more likely to offer pediatric/wellbaby care, children’s activities, and assistance finding housing but were
less likely to offer group or family/couples therapy and educational
information.
A recent study by Wechsberg et al. (48) surveyed 108 methadone
treatment programs accredited by the Commission on Accreditation of
Rehabilitation Facilities (CARF) in 14 states. This study found that 54% of
programs surveyed offered special services for women. Non-profit programs
and programs serving more than 300 patients were more likely to offer such
services than were for-profit programs and programs serving fewer patients.
Sixty percent of programs offered psychological counseling, and transportation was offered at most programs. However, only 10% of programs offered
on-site child care, and only 9% of programs matched female clients to female
providers.
Although there is growing theoretical support for the provision of
specialized women’s substance abuse treatment services, few studies have
investigated whether these programs improve outcomes in women. The
purpose of this article is to provide a comprehensive review of existing
literature evaluating the effectiveness of substance abuse treatment
programming for women. Findings may suggest which types of substance
abuse treatment programming for women should be implemented or require
further evaluation.
24
METHOD
Evidence regarding the effectiveness of substance abuse treatment
programming for women was gathered through a systematic literature search.
This review focused on published literature. Publications from 1980 to
November 2000 were retrieved through a Medline and Psychlit search
performed by cross-matching the term “substance abuse treatment” with the
terms “women,” “child care,” “mental health,” “prenatal care,” and
“transportation.” Relevant references cited in these articles were also included
(i.e., the snowball technique). Other comprehensive reviews of substance
abuse treatment programming for women (2,45,49,50) were also used as a
source for important literature.
To be included in this review, studies must have explicitly defined the
population at risk, the intervention, and appropriate outcome measures to
evaluate the impact of treatment. Outcome measures included changes in the
use of substances, mental health symptoms, perinatal/birth outcomes,
employment, self-reported health status, and HIV risk reduction. Excluded
from this review were studies based in psychiatric facilities and mental health
clinics (unless they used substance abuse treatment outcome measures and
behaviors); brief interventions based at primary care sites, such as smoking
cessation programs; and studies evaluating the effectiveness of educational
interventions not central to substance abuse treatment. For example, Eldridge
et al. (51) evaluated the effectiveness of two interventions to reduce sexual
risk behavior among women in inpatient drug abuse treatment. Outcome
measures included HIV risk reduction, but neither intervention was integrated
into the treatment of substance abuse. Although men may have also used
services at the study sites, the findings presented in these studies are for
women only. Study characteristics were examined, including study period and
location, sample size, race/ethnicity and substance abuse characteristics of
participants, nature of interventions, and multiple treatment outcomes.
RESULTS
Based on the above inclusion criteria, 38 studies were identified. Seven
were randomized, controlled trials (Table 1)a and 31 were nonrandomized
studies (Table 2). The seven randomized, controlled trials included both
a
An additional randomized controlled trial in progress in Tucson, Arizona, has been
described in the literature (52), but results have not been published.
Dahlgren
and
Willander (58)
Elk et al.
(83)
Hiller
et al.
(71)
No.
Race/ethnicity
Population
Interventions
Control group
14
79%
Caucasian
Pregnant, outpatient
methadone clinic
patients
Prenatal care, therapeutic child
care during treatment visits,
monetary rewards for abstinence, relapse prevention
Standard methadone treatment
200
Not reported
Women entering
alcohol treatment
Women-only outpatient and
residential treatment
1994 –
1996,
Houston,
TX
12
59% African
American
Pregnant cocainedependent women
who had used the
drug during this
pregnancy but had
ceased use
1994,
Houston,
TX
17
62% African
American
Women in residential
treatment
Contingent reinforcement for
cocaine abstinence and
attending prenatal visits,
transportation, child care,
behaviorally based drug
counseling, weekly prenatal
visits
Weekly sessions on women’s
health, HIV/AIDS prevention, and assertiveness/
communication skills
Treatment in regular wards and
alcoholism treatment center
Behaviorally based
drug counseling,
weekly prenatal
visits
1990 –
1992,
New
Haven,
CT
1983 –
1986,
Sweden
No specialized
treatment
intervention
Outcomes
At delivery: increased gestational length, birth weight,
and number of prenatal care
visits; no change in maternal
drug use
At 2-year follow-up: decreased
alcohol use, decreased job
loss
At delivery: improved perinatal
outcomes and increased prenatal care, no significant
difference in abstinence from
cocaine
Upon intervention completion:
increased self-esteem, more
positive attitudes toward
practicing safer sex
(continued )
25
Carroll
et al.
(59)
Study
period and
location
Study
citation
Randomized studies of the effectiveness of substance abuse treatment programming for women.
Table 1.
Hughes
et al.
(62)
O’Neill
et al.
(79)
No.
Race/ethnicity
Population
Interventions
Control group
Outcomes
1990–
1992, St.
Petersburg, FL
1992–
1993,
Sydney,
Australia
53
81% African
American
Female cocaine
abusers with
children
Children allowed to live with
mothers in a therapeutic
community
Standard (no child)
community
treatment
By discharge: improved
retention
73
Not reported
Pregnant women
enrolled in methadone maintenance
programs for pregnant women
Methadone maintenance treatment, counseling, and advice
about HIV risktaking behaviors
At 9-month follow-up:
reduction of injecting risk
behaviors associated both
with “typical” drug use and
“binge” use, no change in
sexual risk behaviors, no
change in drug use per se
Not
reported
84
96% African
American
Cocaine-dependent
mothers
Six-session cognitive behavioral intervention focused on
the acquisition of skills
aimed at helping prevent
relapse to needle sharing and
to unsafe sex, methadone
maintenance treatment,
counseling and advice about
HIV risk-taking behaviors
Parenting skills class, access to
a psychiatrist, individual
therapy sessions, GED class
Case managementoriented outpatient treatment
program
At 12-month follow-up:
decreased drug use,
increased program retention,
no change in psychosocial
functioning (including
employment status)
Volpicelli
et al.
(70)
Study
period and
location
Study
citation
Continued.
26
Table 1.
No.
Race/ethnicity
Population
Bander et al.
(80)
1977 – 1979,
Hartford,
CT
167
56% African
American
Low-status women
alcoholics
Bartholomew
et al. (72)
1991 – 1993,
Fort
Worth,
TX
1994, California
81
26% Mexican
American
Women admitted to
outpatient methadone
treatment programs
460
29% African
American
Women participating in
perinatal alcohol and other
drug treatment programs
Berkowitz
et al. (93)
Interventions
Outcomes
Outpatient behavior-modification
counseling, vocational and
recreational activities, medical
care
Assertiveness and sexuality
workshop
At 21-month
follow-up, 19% abstinent 6
months or more; employment
increased from 11 to 26%
Increased length of stay in the
treatment program, greater
increases in self-esteem and
knowledge
Reduction in alcohol and other
drug use; reduction in criminal
activity; reduction in fighting,
inability to care for children,
homelessness, injury and
physical violence, victimization,
and suicidal feelings
Perinatal alcohol and other drug
treatment, child care, transportation, and case management
(continued )
27
Study
period and
location
Study
citation
Non-randomized studies of the effectiveness of substance abuse treatment programming for women.
Table 2.
No.
Race/ethnicity
Population
Interventions
1990 – 1993,
MA
170
72% African
American
Pregnant and parenting
chemically dependent
women at two urban
residential treatment programs
Urban residential treatment
programs with a parenting
component and aftercare
services
Chang et al.
(64)
12
Not reported
Pregnant methadone-maintained opiate-dependent
women
Copeland
et al. (61)
Not
reported,
New
Haven,
CT
1989 – 1991,
Australia
160
Not reported
Women seeking treatment
for drug and alcohol
problems
Prenatal care, relapse prevention
groups, monetary rewards for
abstinence, and therapeutic
child care during treatment
visits
Women-only program, child care
Cuskey and
Wathey
(94)
1974 – 1977,
New
York, NY
97
Almost 50%
African
American
Addicted women who were
pregnant or mothers who
wanted to have their children live with them during
treatment
Residential therapeutic community designed for women and
their children, therapy groups
Longer periods of abstinence;
relatively few infants exhibited
low birthweight, gestational age,
or Apgar scores; dramatic
improvements in self-esteem;
considerable improvement in
parenting knowledge and attitudes associated with positive
parenting behavior
Fewer drug-positive urine screens,
longer gestational ages and
heavier birth weights
No significant differences at
6-month follow-up in substance
use or mental health symptoms
between subjects from a
specialist women’s service and
subjects from two traditional
mixed-gender treatment services
At 6 months after discharge: all
participants were free of drugs,
93% were arrest-free, 14% were
employed
Camp and
Finkelstein
(82)
Outcomes
Study
period and
location
Continued.
Study
citation
28
Table 2.
Not reported
Clients in an all-women’s
alcohol clinic
Women-only alcohol clinic
Egelko et al.
(69)
48
75% African
American
Elk et al. (60)
1992 – 1995,
New
York, NY
Not
reported,
Houston,
TX
35
54% African
American
Perinatal cocaine-addicted
women admitted to the day
treatment program
Pregnant women dependent
on cocaine/opiates
Women-only program with a
multisystems model for family
reintegration
Child care, prenatal care, HIV
counseling, behaviorally based
counseling, transportation
Field et al.
(73)
Not
reported
126
64% African
American
Young mothers (ages 16–
21) who had not completed high school
Grella (68)
1987 – 1994,
Los
Angeles
County,
CA
4117
50% African
American
Women treated in publicly
funded residential treatment programs
Parenting and vocational classes,
relaxation therapy, child care
involving mother participation,
group therapy, psychoeducational sessions, urine monitoring, self-help group sessions,
and individual and drug
counseling
Women-only programs
Lowered frequency of alcohol
consumption, success in stopping alcohol consumption,
decreased use of tranquilizers
and sleeping pills
Improved retention, decreased
substance use
High rate of retention in treatment,
high rate of compliance with
prenatal care, good perinatal
outcomes, high rate of cocaine
abstinence
At 12-month follow-up: lower
incidence of continued drug use,
increased education and
employment, improved motherchild interactions, improved
child psychosocial and physical
functioning, lowered incidence
of repeat pregnancy
Increased length of stay, more than
twice as likely to complete
treatment compared with women
in mixed-gender programs
(continued )
29
44
1985, The
Netherlands
de Zwart (95)
Study
period and
location
No.
Race/ethnicity
Interventions
Outcomes
Comprehensive residential substance abuse treatment program
for women with dependent
children (families living in
independent apartments located
on the facility’s grounds, on-site
child care, individual and group
counseling, life skills training
and instruction, transportation
to community agencies, integration of children through play
and family therapy and recreational activities, etc.)
Outpatient counseling and
prenatal care
73% of participants completed 91
days or more of treatment
Knight et al.
(74)
1996 – 2000,
Fort
Worth,
TX
41
51% African
American
Addicted women admitted to
treatment
Kukko and
Halmesmaki (65)
1985 – 1995,
Helsinki,
Finland
111
Not reported
Drug-abusing pregnant
women giving birth at the
hospital
Laken and
Ager (96)
1990 – 1992,
Detroit,
MI
225
89% African
American
Prenatal substance abusers
Home visits, telephone counseling, transportation, and referral
In 61% of pregnancies, the woman
succeeded in either quitting
totally or reducing drug abuse;
decreased incidence of preterm
birth; higher gestational age and
birth weight
Increased length of stay in an
outpatient treatment program
Population
Study
citation
30
Table 2. Continued.
Roberts and
Nishimoto
(99)
Rosett et al.
(100)
Saunders
(75)
89% Swedish
Pregnant excessive drinkers,
alcohol abusers, and
occasional drinkers
Outpatient maternal counseling
76% of participants reduced or
stopped drinking
55
86% African
American
Therapy group addressing grief
and loss
Increased length of stay, increased
self-esteem
1993– 1994,
Southern
California
1995, not
reported
64
48% African
American
Community-based residential
program for women
369
94% African
American
Women in a gender-specific
residential substance
abuse treatment program
Paroled women who completed substance abuse
treatment while in prison
Women in substance abuse
treatment
Lower self-reported drug use rates,
higher levels of successful parole discharge
Longer length of stay and higher
likelihood of successful program
completion
42
56% African
American
Pregnant problem drinkers
79
73%
Caucasian
Substance-abusing mothers
admitted to residential
treatment
1974– 1977,
Boston,
MA
1990– 1992,
Des
Moines,
IA
Comprehensive woman-focused,
women-only day treatment
program including child care
and transportation
Women-only outpatient
counseling
Two-year program with therapeutic day care, support services
for children, health care, and
educational and vocational
training
35% of participants reduced
drinking before third trimester
Increased abstinence from alcohol
and other drugs; decreased
psychological distress; increased
job, independent living, parenting, and interpersonal skills;
increased mother-child
reunification
(continued )
31
Prendergast
et al. (98)
399
McComish
et al. (81)
1979,
Stockholm,
Sweden
1994– 1996,
Flint, MI
Larsson (97)
Study
period and
location
No.
Race/ethnicity
Interventions
Therapeutic community that
included many features addressing women’s special needs
(women could keep children
with them while in treatment)
Comprehensive focus on
women’s needs (e.g., increasing
male-female client ratios and
female staff, adding women’s
groups/
seminars/retreats, and permitting children to live with
mothers in treatment)
Putting women’s issues and needs
at the center of the therapeutic
community’s efforts (e.g.,
increasing male-female client
ratios and female staff, adding
women’s groups/seminars/retreats, and permitting children
to live with mothers in treatment)
Specialized programs for women
and children
Schinka et al.
(101)
1990 – 1992,
FL
46
81% African
American
Cocaine-dependent women
treated at therapeutic
community
Stevens and
Arbiter
(55)
1994,
Tucson,
AZ
57
25% African
American
Female clients in a
therapeutic community
Stevens et al.
(63)
1981 – 1985,
Tucson,
AZ
Not
reported
Not reported
Female clients in a therapeutic community
Stevens and
Glider
(102)
1991, not
reported
11
Not reported
agencies
Not reported
Outcomes
Improvement in levels of
depression
Decreased alcohol and other drug
use, decreased arrests for
probation violations, increased
part- or full-time employment
and decreased government
assistance, increase in motherchild reunification
Increased length of stay
Increased length of stay
Population
Study
citation
32
Table 2. Continued.
88% African
American
Drug-abusing pregnant
women enrolled in an
urban, hospital-based
obstetric clinic
Pregnant women receiving
prenatal care
On-site support group, free transportation, children allowed to
attend
Heavier birth weights and better
1-minute Apgar scores, lower
short-term medical care costs
Sweeney
et al. (54)
1992– 1995,
Providence, RI
174
35% African
American
Substance abuse treatment program for pregnant and postpartum women
Not reported
Women with mild to moderate alcohol-related problems
22% African
American
Women who had used alcohol or drugs for at least one
year and were either
pregnant or had children
under 7 months of age
Weekly small-group meetings,
alcohol education material,
behavioral self-control strategies
Therapeutic community providing
long-term residential treatment,
modified to fit the needs of
women and children (e.g.,
family-style housing, on-site
therapeutic nursery for children
under the age of 3, parenting
classes, family sessions with a
developmental specialist, scheduling to balance treatment
needs with parenting responsibilities, etc.)
Increased birth weights and gestational ages, less likelihood of
admission to the neonatal intensive care unit
Reduced alcohol consumption
Walitzer and
Connors
(76)
Not
reported
192
Wexler et al.
(84)
1992– 1993,
Tucson,
AZ
83
At 6 and 12 months post treatment:
increases in employment and
decreases in criminality, substance abuse, and psychological
disturbance
(continued )
33
121
1989– 1990,
Baltimore, MD
Svikis et al.
(53)
Study
period and
location
1993 – 1996,
Orlando,
FL
Zankowski
(77)
FY 1986,
Eagleville, PA
Race/ethnicity
Population
Interventions
Outcomes
Groups addressing addiction and
women’s issues, educational
assessment and services, on-site
health care and education,
smoking cessation program,
therapeutic child care services
Multilevel restructuring of
women’s program, including
women-focused seminars
Increased length of stay, increased
child custody, decreased levels
of depression, and increased
self-esteem
86
62% African
American
Pregnant or postpartum
treatment center residents
Not
reported
50% African
American
Female patients at a large
acute-care drug and alcohol treatment hospital
Increased retention of women in
treatment
Wobie et al.
(56)
No.
Study
citation
34
Table 2. Continued.
35
American and international studies, with sample sizes ranging from 14 to 200
subjects. International studies originated in Sweden and Australia. Subjects in
both randomized and nonrandomized studies were either pregnant women,
women with children, or women in treatment regardless of parenting status and
were either predominantly Caucasian or predominantly African American.
Substances used by subjects included alcohol, cocaine, and injecting drugs.
Interventions included prenatal care, child care, women-only treatment,
transportation, mental health services, sessions on women’s issues, and
combinations of these components.
Most studies addressed the question of whether substance abuse treatment
programming for women produces better outcomes than those produced by
other types of programming. Only two of the selected studies specifically
addressed the question of whether substance abuse treatment programming for
women produces better outcomes than does no treatment (53,54). Two other
studies compared women who dropped out of women-focused substance
abuse treatment with those who completed such treatment (55,56).
We used two major criteria to evaluate evidence of the effectiveness of
substance abuse treatment programming for women: study design and
consistency of findings. A third criterion, strength of association, was not
specifically considered to evaluate effectiveness but was used to determine
overall impact. A recent study by Orwin et al. (50) included a meta-analysis
evaluating the effectiveness of 33 substance abuse treatment programs for
women. Orwin et al. defined strength of association, or effect size, as the
standardized mean difference between groups.
Optimally, health interventions are evaluated through study designs using
randomized, controlled trials, the standard method for establishing efficacy
(57). An example of the best evidence would be a controlled clinical trial or
series of trials in which women are assigned to a “standard” program
representing typical substance abuse treatment or a “women’s” program, and
long-term results are compared. To avoid confounding, the standard program
should be compared with just one additional element of the women’s program.
Of the seven randomized, controlled trials reviewed here, Dahlgren and
Willander’s study (58) came closest to this study design. Women were
randomly assigned to treatment in either a regular ward/alcoholism treatment
center or a women-only outpatient or residential setting. Results were
compared after 2 years. The 7 randomized trials differed in interventions and
methodologies, whereas the 31 nonrandomized studies used a variety of
descriptive, cohort, preexperimental, and quasi-experimental study designs.
Consistency refers to the replication of findings by different studies with
different populations. The studies reviewed here varied widely in study
populations. For example, prenatal care was provided as an intervention to
36
methadone patients in one study (59) and to cocaine-dependent women in
another (60). Of the 38 studies analyzed, 37 reported improved treatment
outcomes. As summarized in Table 1, all seven randomized, controlled trials
showed positive results. Three studies showed decreased substance use and
increased program retention. Two showed no change in substance use but
increased gestational length and birth weight; decreased occurrences of
premature rupture of the membranes, preterm labor, preterm birth, and low
birth weight; and increased prenatal care. One showed decreased injecting risk
behaviors but no change in sexual risk behaviors or drug use per se, and the
last showed positive psychosocial and HIV prevention outcomes. Thirty of the
31 nonrandomized studies showed positive results, including those for (in
order of frequency) length of stay, decreased substance use, improved
perinatal/birth outcomes and prenatal care, self-esteem and depression, and
HIV risk reduction (Table 2).
The one study that did not report improved treatment outcomes was
conducted in Australia. This study found no differences in treatment outcomes
for 80 women in a women-only program and 80 women in two mixed-gender
treatment programs (61). Both the women-only program and the mixedgender treatment programs were based on the traditional disease model and
12-step philosophy, but the women-only program employed only female staff
and provided residential child care. The characteristics of clients entering
treatment did differ, however, with more lesbian women, women with
dependent children, and women with a history of childhood sexual abuse or
maternal substance abuse participating in the women-only program.
In this review, we explored the effects of specific components of
substance abuse treatment programming for women: child care, prenatal care,
women-only admissions, supplemental education sessions that address
women-focused topics, mental health programming, and comprehensive
programs that combine multiple components. Transportation was infrequently
provided within the studies reviewed and was not evaluated by any study as a
primary intervention; therefore, it is not discussed independently of other
components.
Child Care
Most of the studies that evaluated the impact of child care examined
services for children living with their mothers in residential treatment settings.
Some of these programs also provided therapeutic care for siblings living
nearby. Child care services often included care coordination among
developmental evaluation services and children’s treatment providers or
37
support services, such as counseling and tutoring, for school-age children in
the evenings.
In a clinical trial by Hughes and associates, women who lived with their
children in therapeutic community treatment programs remained in treatment
significantly longer than women whose children were placed with caretakers
(62). Fifty-three women were randomly assigned to either the standard
community condition ðn ¼ 22Þ; in which children were placed with the best
available caretaker, or the demonstration condition ðn ¼ 31Þ; in which one or
two of the children lived with their mother in the therapeutic community.
Survival analysis indicated that women who were allowed to remain with their
children remained in treatment significantly longer (mean length of stay
300 days) than did women whose children were placed with caretakers (mean
length of stay 102 days). Less rigorous studies also found that programmatic
changes aimed at addressing women’s needs and allowing women to bring
their children into residential treatment were associated with increased length
of stay (e.g., Refs. 56,63). A study by Wobie et al. (56) suggested that the
earlier a mother’s infant resides with her in the treatment setting, the longer the
mother will stay in treatment. In addition, measures of depression were lower
and measures of self-esteem were higher for women with their infants than for
clients who did not have their infants in the treatment facility. In some studies,
child care was provided to study participants, but its impact was not evaluated.
For example, child care made it possible for women with preschool-age
children to participate in one study (59) and proved essential to the effective
recruitment and retention of women in another study (60).
Prenatal Care
Four studies have evaluated the impact of prenatal care on treatment
outcomes. A small-scale randomized trial study conducted by Carroll et al.
(59) compared standard methadone maintenance to an enhanced treatment
program that offered prenatal care, relapse prevention groups, positive
contingency awards for abstinence, and therapeutic child care. A second study
by Chang et al. (64) involved a nonrandomized experiment for the same
intervention. Both studies found that women in the enhanced methadone
program had three times as many prenatal visits and better birth outcomes than
women in the standard program, but both studies used small samples.
Two studies examined the effectiveness of mental health interventions
coupled with prenatal care, child care, HIV counseling, parenting and nutrition
classes, and transportation (60,65). These studies reported high rates of
abstention from drug use or reduced drug use, retention in treatment,
38
compliance with prenatal care, and good perinatal outcome. Two additional
studies evaluated substance abuse treatment interventions among pregnant
women (such as comparing women enrolled in prenatal care with women
enrolled in both substance abuse treatment and prenatal care), but these studies
did not evaluate the effectiveness of prenatal care (54,66).
Women-Only Programs
Single-gender treatment is often advocated for women because substance
abuse treatment programs tend to be male dominated in terms of number of
patients and treatment approach (67). Single-gender treatment can be
organized at the program level or, alternatively, at the group level within
mixed-gender programs. The literature contains many reports of all-female
treatment programs. However, only one randomized study in Sweden
conducted by Dahlgren and Willander (58) compared women treated in a
female unit consisting of an outpatient clinic and a residential ward to women
placed in the care of traditional mixed-gender alcoholism treatment centers. A
2-year follow-up of patients showed a more successful rehabilitation both in
terms of alcohol consumption and social adjustment (including employment
status) for the women treated in the specialized female unit.
Using a nonrandomized design, Grella’s study (68) of 4117 women
treated in publicly funded residential treatment programs in Los Angeles
compared outcomes from women-only and mixed-gender programs. Although
women in women-only programs reported that they had more problems, they
actually spent more time in treatment and were more than twice as likely to
complete treatment than were women in mixed-gender programs.
Copeland et al.’s study (61) compared the results achieved by 80 subjects
from a women-only treatment program with the results for 80 subjects from
two traditional mixed-gender treatment programs. All programs used group
therapy and an introduction to the 12-step treatment philosophy. The womenonly treatment program also used a feminist-oriented treatment approach,
including female counselors and child care. At entry into treatment, the
women-only program had significantly more lesbian women, women with
dependent children, women sexually abused in childhood, and women with a
maternal history of substance dependence than did the mixed-gender
programs. Six months following treatment, there were no significant
differences in any measure of treatment outcome between the women in the
two types of treatment programs, including self-reports of alcohol or drug use,
a detoxification episode, a drug-related conviction, and AA/NA attendance.
39
Other studies have evaluated treatment models using women-only groups
introduced within mixed-gender programs, such as a multisystems model for
family reintegration (69) or psychosocially enhanced treatment (70).
Volpicelli et al. (70) randomly assigned cocaine-dependent mothers to either
a case management-oriented outpatient treatment program or a psychosocially
enhanced treatment (PET) program. Both programs offered outpatient group
therapy-based treatment, on-site child care, and daily women-only group
therapy sessions. The PET program also offered services such as unlimited
individual therapy sessions and access to a psychiatrist. Analyzed with use of
linear regression, program retention was significantly better for patients in the
PET group ðt ¼ 2:1; p ¼ 0:038Þ: Overall, PET patients averaged 15.4 weeks in
treatment, compared to 13.9 weeks for the case management group. Although
cocaine use decreased from baseline levels in both groups, the PET group had
significantly fewer days of cocaine use at 12-month follow-up than did the
case management group ðt ¼ 2:16; p , 0:04Þ:
Use of Supplemental Education Sessions
Supplemental education sessions consisted of structured groups (typically
women only) within a substance abuse treatment program. Sessions often
involved dissemination of materials and provision of social support among
participants. One randomized study by Hiller et al. (71) evaluated a standard
substance abuse treatment program supplemented with psychosocial workshops that consisted of weekly sessions on topics such as breast health and
breast self-examination; sexual and reproductive anatomy; sexually
transmitted diseases (STDs), including HIV and acquired immune deficiency
syndrome (AIDS) prevention; plus assertiveness and communication skills.
This approach was associated with more positive attitudes toward practicing
safer sex and increased self-esteem. These types of supplemental
psychoeducational sessions and workshops were also evaluated in several
nonrandomized studies. Standard substance abuse treatment supplemented by
workshops was evaluated both as the primary focus of an intervention (72) and
in combination with other components. The other components included child
care and prenatal or health care (56,73 – 75), the provision of educational
materials and behavioral strategies (76), and comprehensive program
restructuring to address the special needs of women (55,63,77).
Workshops, training, and groups focused on women’s issues have been
identified elsewhere as techniques effective in dealing with substance abuse
problems of women (49,78). Although topics such as sexual health may have
40
appeared tangential to substance abuse treatment, they may nevertheless have
resulted in increased length of stay in treatment and improved outcome.
Mental Health Components
As mentioned previously, one study by Volpicelli et al. (70) randomly
assigned 84 cocaine-dependent mothers to either a case management-oriented
outpatient treatment program or to a PET program that offered access to a
psychiatrist, individual therapy sessions, classes on parenting, and high school
equivalency education. Because individual therapy was the most extensively
used service in the PET group, the authors speculated that individual therapy
may have been the primary cause of PET’s marginally better outcomes.
Another study randomly assigned pregnant injecting drug users either to a sixsession cognitive behavioral intervention in addition to their usual methadone
maintenance treatment or to their usual methadone maintenance treatment
only (79). At a 9-month follow-up, the intervention group had significantly
reduced some HIV risk-taking behaviors (in particular, injecting risk
behaviors associated both with “typical” drug use and “binge” drug use).
Kukko and Halmesmaki (65) evaluated the efficacy of a counseling
program for drug-abusing pregnant women. In 61% of pregnancies, the
woman succeeded in either quitting totally or reducing drug abuse, resulting in
lowered incidence of preterm birth and increased gestational age and birth
weight. Bander et al. (80) reported on a program providing a combination of
individual and group counseling, home and hospital visits, cultural and
recreational activities, vocational training, employment counseling, access to
medical care and legal advice, and bus passes to inner-city women alcoholics.
At a 21-month follow-up, 19% of the patients were judged by their counselors
to have been abstinent 6 months or more, and 26% of the patients were
employed during their involvement with the program. Field et al. (73)
investigated the effects of an intervention for polydrug-using adolescent
mothers, consisting of group therapy, psychoeducational sessions, urine
monitoring, self-help group sessions, and individual and drug counseling. The
program also included child care and educational, vocational, and parenting
classes. At 12 months, participants demonstrated a lower incidence of
continued drug use and repeat pregnancy, and a greater number continued
school, received a high school or general equivalency diploma, or were placed
in a job. The drug-exposed infants (compared to a non-exposed control group)
had improved psychosocial functioning, as well as significantly greater head
circumference and fewer pediatric complications.
41
The effectiveness of a therapy group addressing grief and loss among
women enrolled in a gender-specific residential substance abuse treatment
program was examined in another study (81). Women who participated in the
grief group remained in treatment longer and had higher self-esteem at followup. A seventh study examined the living arrangements of mothers and babies
in a residential treatment center that offered mental health programming, but it
did not evaluate the effect of mental health programming per se (56).
Comprehensive Programs
Although several studies evaluated combinations of components that
address women’s needs (e.g., Refs. 70,82,83), certain studies described
programs worth noting for their comprehensiveness in integrating women’s
needs into substance abuse treatment programming. Knight et al. (74)
described a 12-month residential program for women with dependent children
in which children were integrated into the treatment program through play
therapy, family therapy, and recreational activities. Women applied what they
learned in workshops, such as opening a savings account and making regular
deposits, to help them strengthen basic life skills, build positive habits, and
begin to plan for the future.
Stevens and Arbiter (55) described a therapeutic community that provided
long-term residential treatment for addicted pregnant women and women with
children. Under the direction of a female program director, the 18-month
therapeutic community program put women’s issues and needs at the center of
its efforts. Aspects of the interventions included the following modifications:
1) increasing the number of female staff members or role models who are
recovering substance abusers; 2) adding groups/seminars that focused
specifically on women’s issues (e.g., emotional safety, building female
friendships, molestation, rape, abortion, prostitution, children); and 3) allowing children to live with mothers in treatment. Comparing women who
completed treatment with those who dropped out, the authors found decreased
alcohol and other drug use, fewer arrests for probation violations, less
unemployment, and decreased reliance on government assistance among
treatment completers.
Wexler et al. (84) presented findings from a later study of this same
therapeutic community. Further modifications were made for the later study
so that appropriate family-style housing for the mother and children
was possible, and an on-site therapeutic nursery for children under the age
of 3 could be provided. Changes in the program were also made to
include parenting classes; family sessions with a developmental specialist;
42
after-school programs for the preschool and school-age children; an additional
focus on nutrition and health, especially for the pregnant women; and
adjustment of the schedule for curriculum and other daily activities to balance
the women’s treatment needs with parenting responsibilities. Major 6- and
12-month posttreatment improvements included increases in employment and
decreases in criminality, substance abuse, and psychological disturbance.
Wobie et al. (56) examined the effects of babies living with their mothers
in a residential treatment center that provided addiction and parenting groups;
assessment and coordination of educational needs; on-site health care and
health care education; smoking cessation programs; therapeutic child care;
mental health counseling; addictions counseling; various other groups, such as
play groups for mothers and babies; and workshops on self-esteem, sexual
abuse, sexual orientation, and HIV and AIDS awareness. Findings suggested
that the earlier a mother’s infant resides with her in the treatment setting, the
longer her length of stay will be. In addition, measures of depression were
lower and measures of self-esteem were higher for women with their babies
than for clients who did not have their infant in the treatment facility.
DISCUSSION
Review of the literature on the effectiveness of substance abuse treatment
programming for women identified 38 studies of the effect of such
programming on substance abuse treatment outcomes. Study characteristics
and program components were examined. The studies were separated into two
groups based on study design: randomized, controlled studies and nonrandomized studies. Within each group, findings consistently showed
improved treatment outcomes, based on multiple measures of outcome. The
studies reviewed here provide some evidence of the effectiveness of the
following six components of substance abuse treatment specifically designed
for women:
1.
2.
3.
4.
5.
6.
Child care,
Prenatal care,
Women-only admissions,
Supplemental services and workshops that address women-focused
topics,
Mental health programming,
Comprehensive programming.
43
Prior reviews of one or more of these components also found positive
outcomes. Duckert’s review (49) indicated that most women-only programs
reported favorable outcomes (e.g., 20% – 60% of participants improved their
drinking outcomes). Orwin et al. (50) found almost uniformly positive mean
effect sizes when they compared women-only and traditional mixed-gender
treatment programs. Findings from that analysis also suggested that enriching
women-only or female-sensitive mixed-gender treatment programs with
enhancements such as prenatal care, therapeutic child care, or HIV prevention
intervention adds value above and beyond the effects of standard, women-only
programs. Howell et al. (2) reviewed the literature on outcome studies of
substance abuse treatment for pregnant women, suggesting that retention is
facilitated by the provision of support services such as child care, parenting
classes, and vocational training. Marsh and Miller’s review (45) concluded
that programs that provide ancillary services such as child care and those that
involve family members and significant others hold the greatest promise for
women with drug and alcohol problems. It is important to note that programs
with such services may increase the number of women and alter the type of
women who receive treatment (e.g., women who need child care).
There are several possible explanations for the consistent findings of
positive outcomes associated with substance abuse treatment programming for
women. First, certain components of substance abuse treatment programming
for women may reduce barriers to treatment entry and retention. Research
suggests that the provision of child care may facilitate women’s entry into or
completion of drug abuse treatment (34). In addition, Copeland and Hall’s
(28) research suggests that women-only programs may be more able to attract
and retain women in treatment than mixed-gender programs because women
with a history of trauma and other women (e.g., lesbian women and those who
have worked as prostitutes) are especially vulnerable to humiliation in mixedsex treatment services. Second, combining substance abuse treatment and
supplemental services such as prenatal care, workshops, and mental health
programming may increase the likelihood that women will receive
supplemental services. In particular, prenatal care has been linked to
reductions in the adverse effects of ongoing maternal drug abuse (85). Third,
such services may provide emotional and tangible supports to allow
substance-abusing women to concentrate on recovery and may give special
attention to women who generally feel stigmatized because of their substance
use and rejected by health professionals (86).
There are several important limitations of our findings. First, our
findings may not be generalizable to all treatment programs and treatment
populations because we focused on peer-reviewed articles only. In contrast
to the fugitive literature, peer-reviewed articles may be more likely to
44
present positive results (87,88). Second, most of the articles reviewed here
used nonrandomized designs, although randomized, controlled trials will
remain invaluable in analyzing the effectiveness of substance abuse
treatment programming for women. Other potential limitations are the
small sample sizes used by many studies and differences in outcome
measures, measurement instruments, and procedures, which make
comparisons of studies difficult. Furthermore, many of the studies used
self-reported data, which have in general been demonstrated to be reliable
and valid (89) but which may not be fully reliable for the populations in
question here, such as perinatal populations (90). To substantiate or
complement the information derived from participant self-report, research
protocols for future studies of effectiveness of substance abuse treatment
programming for women should include corroborating evidence from
external sources of information, such as health care providers, social
services agencies, and criminal justice records.
Follow-up periods varied widely among studies. Many studies acknowledged that it was not possible to find some women after they left treatment,
necessitating the use of data available at discharge. Long-term randomized,
controlled trials using standardized data collection instruments will provide
vital information about the effectiveness of substance abuse treatment
programming for women.
Few of the studies identified in this or any previous review evaluated costeffectiveness. In their analysis of neonatal intensive care and drug treatment
costs, Svikis et al. (91) used cost-effectiveness criteria in comparing outcomes
for two samples, a treatment ðn ¼ 100Þ and a nontreatment ðn ¼ 46Þ control
group. Service measures included costs per mother/infant pair and duration of
neonatal intensive care. Treatment patients showed better clinical outcome at
delivery, with higher average infant birth weight measures and Apgar scores.
These outcomes, adjusted for differences in age, education, and income, were
statistically significant. The authors also reported significant mean net savings
for the sample of women who attended substance abuse treatment, compared
to the cost for non-treatment controls ( p , 0:01; controlling for age,
education, and cocaine use).
Another study by Williams compared the costs of crime and treatment for
detoxification only, methadone only, residential only, and residential/
outpatient combined within a sample of 439 pregnant women who entered
publicly funded treatment programs (92). Projected to a year, the avoided
costs of crime minus treatment costs ranged from $33,000 for residential only
to $3,000 for detoxification. Multivariate regressions controlling for baseline
differences between the groups showed that reductions in crime and related
costs were significantly greater for women in the two residential programs.
45
Additional research studies with cost-effectiveness evaluation components are needed to provide a sufficient basis for future funding decisions
regarding substance abuse treatment programming for women. However, there
are a number of important clinical measures that also need to be employed, and
programming for women should not be judged solely on the basis of whether it
saves money. Preferably, the estimated cost-effectiveness of programming for
women should be compared with that of traditional substance abuse treatment
programming. To make reliable comparisons, however, cost-effectiveness
analyses must use data from better controlled studies.
In conclusion, this review suggests that for substance-abusing women,
treatment programming that includes components that specifically address
women’s needs can be beneficial. Programs that narrowly define the problems
women face solely as drug and alcohol abuse may not substantially improve
outcomes. This review underscores the continued need for well-designed
studies of substance abuse treatment programming to improve the future
health and well-being of women and their offspring.
ACKNOWLEDGMENT
The authors thank Donald Goldstone, Charlene Lewis, Kathleen Jordan,
and Wendee Wechsberg for their helpful reviews. They also thank Jennie
Harris for research assistance.
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